A Primer on Medical Student Well-Being American Medical Student Association 1902 Association Drive Reston, VA 20191 This and other publications are available through the American Medical Student Association 1902 Association Drive Reston, VA 20191 (703) 620-6600 Web site: www.amsa.org This resource was researched, prepared and written by Eunice Marie Santiago AMSA Well-Being Intern esantiago@medmail.com and Eric Hodgson AMSA Director of Student Programming 2000-2001 ejmdreston@aol.com Do you have any comments, questions, or concerns? Please contact the Director of Student Programming At (703) 620-6600 ext. 270 dsp@www.amsa.org TABLE OF CONTENTS INTRODUCTION 5 AMSA’s MISSION 5 STRESSING OUT LOSING CONTROL (Suicide) CHECKS AND BALANCES COPING STRATEGIES/LEARN TO RELAX 6 6 7 7 DAZED AND CONFUSED (Sleep Deprivation) THE OPPOSITION YOU ARE NOT ALONE SO…SLEEP ON IT 8 8 8 9 ON SUBSTANCE ABUSE DRINK LIFE TO THE LEES QUICK FACTS 10 10 10 ON A CULTURE OF ABUSE PUTTING WORDS INTO ACTIONS 11 11 FREQUENTLY ASKED QUESTIONS 12 ONLINE RESOURCES 13 NOTES FOR CONCERNED MEDICAL STUDENTS BY PATCH ADAMS 14 CITATIONS 15 GOOD “WELL” HUNTING The Wellness Balance Model Physical Physical fitness/Ability/Active living Body Awareness/Positive body image acceptance Nutrition/Eating behaviors Safety/Injury prevention Substance Use: alcohol and other drugs (prescription, non-prescription, tobacco) Sexual health/STIs/Pregnancy Medical history/Self-care Intellectual Critical thinking/Problem-solving Mental status/Abilities/Challenges Stimulation/Creativity Education/Learning history Adaptation to change Accessing resources Occupational Career planning/Academic program Occupational interests/Influence of others Work history/Skills Economic outlook Vocation/Avocation/Leisure balance Child-rearing/Homemaking Volunteerism Spiritual Sense of belonging/Bonding Religious/Spiritual history/Belief system Sense of purpose/Direction/Meaning Beliefs about death/suffering Willingness to seek guidance Life satisfaction/Positive acceptance of life Social Interdependence/Willingness to seek help from and give help to others Finances/Housing Interaction of self with community and environment Psychosocial history/Social network Relationship style/Significant relationships Acceptance of others regardless of race, ethnicity, religion, gender, ability or sexual orientation Emotional Self-awareness/Self-esteem/ Self-efficacy Positive attitudes/Values/Beliefs Communication skills Coping skills/Assertiveness Decision-making skills Caring/Healthy relationships Mental health/Psychiatric history NOTE: The wellness balance model and the dimensions of wellness information given above are taken from Student Health Service (1999). Wellness Planning Guide. The University of B. C. ©American Medical Student Association/Foundation, 2001 INTRODUCTION and suicide. These statistics are extremely For centuries, medicine has been regarded as alarming because they represent those a gratifying and honorable career. Medical students start their education with a sense of individuals entrusted with the health care of our nation. commitment, enthusiasm, optimism, altruism, and idealism, while graduate Altogether, if a future physician’s potential doctors are expected to be caring, is reduced or destroyed by any of these humanistic, compassionate, and dedicated to 1 factors, the result will inevitably be poor their patients. healthcare delivery. Thus, it is imperative to encourage medical schools as well as However, the pursuit of a medical career students to assume responsibility for their exacts a heavy toll on the student’s health own physical, mental, and spiritual welland well-being, since there is a heavy being. emphasis on technical excellence and amassing of information with little regard of Considering that the philosophy that students’ social and emotional development. underlies the promotion of health and wellThere is generally a shift to a more cynical being is based in primary prevention, this and hedonistic orientation during medical primer aims to 1) provide an overview of school as well as significant elevations and 2 various well-being issues pertaining medical increases in depression and anxiety. education; 2) illustrate how a lack of Increasing attention has been paid to the physical and emotional wellness proves to problems affecting the medical population be detrimental to medical students; and 3) with rather startling statistics that describe provide students with a list of available significant amounts of drug and alcohol resources to better understand and cope with abuse, severe depression, deleterious effects the multiple stresses inherent in medical of sleep deprivation, medical student abuse, education. AMSA’s MISSION AMSA is committed to improving health profession of medicine; to contributing to care and health care delivery to all people; to the welfare of medical students, interns, promoting active improvement in medical residents, and post-MD/DO trainees; and to education; to involving its members in the advancing the profession of medicine. social, moral and ethical obligations of the “The purpose of AMSA is to promote improvements in health sciences education so that the educational environment fosters growth of the student as an integrated mental, physical, and spiritual being. AMSA defines health as a positive, dynamic state of physical, mental, and environmental well-being, and therefore, believe that health care should be oriented toward the achievement of health and not solely a treatment of disease.” (AMSA-1977)3 “Enthusiasm is contagious. Be a carrier” –Susan Rabin 5 ©American Medical Student Association/Foundation, 2001 STRESSING OUT ! Anger/Irritability Stress is a normal part of everyone’s life. A ! Weight Gain/Loss certain amount of stress clearly enhances ! Ulcers performance and productivity. When properly handled, stress can make your life more interesting and exciting. According to recent studies, the rise in depression scores and their persistence over A recent study4 found that those medical time suggests that emotional distress during students participating in stress-management medical school is chronic and persistent programs demonstrated: rather than episodic.5 At one medical school, 12% of the students became clinically • Improved immunologic functioning depressed during their first year6, and 30% • Decreases in depression and anxiety of residents during their intern year.7 • Increased spirituality and empathy A number of studies have beem conducted on the perceived stressors, problems, and concerns of medical students such as: • Academic demands • Financial responsibilities • Sleep deprivation. However, stress can become oppresive when it is not managed properly giving rise to a series of physical, mental, and spiritual difficulties. Among the most common effects caused by stress are: ! Depression ! Headaches ! Hypertension “Physicians should strive to manage professional and personal stress to maintain their own health and wellbeing and to maximize their ability to provide quality health care to their patients.” (CMA Policy, 1998)8 LOSING CONTROL ( Suicide) Suicide is a critical issue among the medical population. Each year, physician suicide removes from the U.S. a number of physicians equal to the size of a medical school graduating class.9 At present, researchers have been unable to establish absolute causes for suicide among this population. However, there are a series of factors that have been identified as precursors to suicide such as: ♦ Alcohol/substance abuse ♦ Previous psychiatric history ♦ Violent/aggressive behavior According to a study performed in 199610, suicide ranks second among the leading causes of death among medical students; 40% of these occurred in the junior year. As for physicians, the estimated suicide rate is twice that of the general population-- selfpoisoning with prescribed drugs the predominant method.11 Other potential risk factors inherent in medical education such as work stress and sleep deprivation may contribute to the suicide rates. For this reason, students and physicians must cooperate and seek help before it’s too late. “The moment man begins to question the meaning and value of life he is sick” –Sigmund Freud 6 ©American Medical Student Association/Foundation, 2001 CHECKS AND BALANCES The health benefits of emotional ventilation functioning relationship, be it with a patient, and support have been proclaimed for a friend, a professor, or a significant other, centuries. Physicians who balance work, requires a sense of working harmoniously family, physical, emotional, and spiritual together12--it can brighten your day. Likewise, a healthy intimate relationship is needs are happier, healthier, clearer in vital to most people, including physicians. thought, more energetic, and more The medical profession needs a cultural shift accepting. While this may seem like the physicians’ Utopia, it is definitely attainable. from the belief that a physician’s calling transcends family life. Healthy relationships are a key component of achieving balance. A healthy and “We cannot direct the wind but we can adjust the sails” –Anonymous COPING STRATEGIES☯LEARN TO RELAX Create a relaxing scene, for a moment, It is very important for medical students to acknowledge that some stress factors are daydream your cares away. controllable and others are not. We may not Cultivate humor. Sometimes laughter is the be able to get rid of stressful events, but we best medicine. Laughter has been shown to release hormones into the brain that make can certainly control the way in which we deal with them. you feel good. ☺ Avoid self-medication. Always consult Know your limits. It's okay to say "no" to your physician if you feel sick or depressed. extra commitments and projects. Assess your stress. Make an effort to Self-medication may be habit-forming, reduce your efficiency, and create even master, overcome, or counteract your stressors instead of trying to live with or more stress. escape them. Change the scenery. Go for a brisk walk. Light exercise can be refreshing. Be good to yourself. Eat a well-balanced diet; avoid caffeine and fatty foods. Take a There may be times when you feel your stress and its effects become too great for break from your daily routine to just relax. Share your stress. Talk to someone you you to handle alone. Before stress gets out trust about your concerns and worries. of hand, seek professional help to prevent a Imagery. Translate your feelings into ideas. more serious situation later on.13 “AMSA supports the development of high quality, confidential counseling services for students desiring such services and encourages efforts to educate both students and faculty as to the benefits of such counseling so as to dispel the myth that recourse to counseling is an indication of weakness in the student; we also support the confidentiality of medical student health and counseling records and affirm that the student, as patient, deserves, as does anyone, the privilege of confidentiality between doctor and patient.” (AMSA-1977) “The trouble with life in the fast lane is that you get to the other end in an awful hurry” -J.J. 7 ©American Medical Student Association/Foundation, 2001 DAZED AND CONFUSED ( Sleep Depriv a t io n) • Most adults need around eight hours of sleep for peak alertness and energy. Due to a myriad of reasons ranging from insomnia to work schedules and even having a baby, this has become the exception, not the rule. • • • • • Sleep deprivation is one of the main causes of physician-in-training impairment. Researchers have found that prolonged periods of duty without sleep adversely affect practitioners, both in their well-being and in their ability to carry out simple tasks.14 Sleep deprivation can produce severe psychological symptoms such as perceptual and mood changes, psychosis, irritability, decreased ability to concentrate, and anxiety.15 Increased fatigue, depression, and hostility16 Poor psychomotor performance Deterioration of doctor-patient relationships Recent memory loss Extreme sensitivity to criticism17 Car accidents-death18 In 1984, Libby Zion, an 18 year old girl, died because of an adverse reaction to two medications. After the investigation, the grand jury concluded that the long working hours of residents had contributed to her death, and the doctors were required to pay $375,000 to the Zion family for pain and suffering.19 On account of this, in 1989 New York became the only state in the U.S. to regulate resident hours, as established by the Public Health Law Code 405, known as the Bell Regulations.20 Among the prevailing effects caused by sleep deprivation are: THE OPPOSITION To add insult to injury, Dr. Ward Griffen, You may think the Bell Regulations solved the problem. However, the situation is less head of the American Board of Surgery, than ideal. Although the regulations are in emphatically stated that he thinks, “it’s the place in NY, they are not always enforced. biggest bunch of hogwash there is. All this According to an investigation performed in jazz about sleep deprivation is way overplayed…I think the people who are 199821, nearly all the residents at the seven hospitals investigated in NYC worked pushing this are the ones who can’t get by longer hours than the laws allow (surgery on a little sleep.”22 programs being the worst offenders.) YOU ARE NOT ALONE “AMSA recognizes that patient care and medical education suffer when students and housestaff lack proper rest; believes that students should be allowed to negotiate working hours and conditions with their respective medical institutions; and therefore supports and will work toward the implementation of regulations, including those at the federal level, which will regulate resident work hours with the intent of providing a better standard of care for all patients and more humane working conditions for residents.” (AMSA-1977) “Health care students can be taught from the beginning of their careers that they have as much responsibility for their own sanity and physical well-being as they do for those qualities in the lives of their patients.” –Donald A. Block, M.D 8 ©American Medical Student Association/Foundation, 2001 SO…SLEEP ON IT! There is still much to be done regarding things students can do to improve their residents’ working hours and it will take health, thus, ensuring a successful career as some time. Nevertheless, there are many physicians and a better healthcare delivery. “Let us emancipate the student, and give him time and opportunity for the cultivation of his mind, so that in his pupilage he shall not be a puppet in the hands of others, but rather a self-relying and reflecting being.” –Sir William Osler Second: Beat Insomnia 1) Maximize your comfort. A firm mattress and pillow work best. Make your room quiet, dark and cool with good air circulation. To block out traffic or other noise, try ear plugs or soothing nature tapes. 2) Take a warm bath. Baths help lower your body’s temperature which makes you feel sleepier. 3) Drink warm milk or herb tea. Milk and bananas contain L-Tryptophan, which is thought to induce sleepiness. Herb tea is a good substitute for those who are avoiding dairy products. The ritual of drinking something warm can relax you. 4) Do some light reading. Choose a book that you can put down easily—a humorous work, a short story, a favorite childhood tale. 5) Savor your last hour before bed. Save intense conversation for another time. Avoid TV altogether—the flickering lights stimulate your nervous system. Did you know? First: Why Can’t You Sleep? According to the National Commission on Sleep Disorders of Research, insomnia afflicts about 40% of women and 30% of men. The following are the top five factors: • Stress—Stress increases heart rate and blood pressure, raising arousal level. • Depression—Depressed people often wake up early and have trouble falling asleep again, a condition called “sleep maintenance” insomnia. • Alcohol—Alcohol may help you fall asleep, but it results in light, fragmented sleep. After the sedative effect wears off, usually in four hours, there is a rebound effect that can leave you wide awake in the middle of the night. One drink or glass of wine is okay with dinner, but no alcohol within two hours of bedtime. • Caffeine—Coffee, cola and other caffeinated substances produce a buzz, not by jazzing us up, but by preventing us from slowing down. Caffeine buzz lasts 6-8 hours, so if you can’t sleep, limit caffeine to early in the day or avoid it altogether. • Food or exercise too close to bedtime— Both vigorous exercise and eating a meal temporarily boost the body’s metabolism, which can chase away sleep. Schedule a strenuous workout or a big meal no less than three hours before bedtime. This gives the heart rate and metabolism time to slow down enough for sleep. Peak hours for… Creativity 9–11 am (good time to do most of your important work) Day Dreaming 2 pm (good time for artists and writers) Coordination and reflexes 5 pm (great time to exercise) “Healthy medical students are likely to become healthy doctors who can then model and promote healthy lifestyles with their patients.” –Dr. Thomas M. Wolf 9 ©American Medical Student Association/Foundation, 2001 ON SUBSTANCE ABUSE For instance, a Surgeon General’s report on Research studies have shown that the prevalence of alcohol and illicit drug abuse smoking and health concluded that between among physicians is similar to that of the 10% and 25% of smokers who are advised to quit by their physician quit smoking or general population, while abuse of prescription drugs may be more prevalent.23 reduce the amount they smoke. 25 Substance abuse gives cause for concern not only because medical students themselves may suffer as a result, but also because of the potential impact on their effectiveness as tomorrow’s doctors.24 The preventive care beliefs and practices of health professionals are noted by the general public and influences patient behavior, since physicians are almost unquestioned in their judgements. On the other hand, studies have repeatedly shown that the medical profession as a whole tends to have negative attitudes towards the management of patients with substance abuse problems.26 In which case, it is fair enough to think that they will be less likely to acknowledge the problem in themselves. “AMSA aims to promote improvements in health sciences education so that it fosters a compassionate understanding of substance abuse problems and mental illness, with a goal toward reducing their stigma in the profession and for the public at large.” (AMSA-1977) DRINK LIFE TO THE LEES Inclusion of substance abuse programs in medical institutions should concentrate their medical schools’ curricula has proven to be efforts on the implementation of programs very successful. Students learn about the directed toward prevention, treatment, and nature of chemical dependency and its rehabilitation. Currently, there are no treatment, thereby, gaining critically absolute ways to prevent substance abuse. important skills in caring for themselves and However, what can be done is to create their patients, as well as monitoring the awareness among your peers about the activities of their peers.27 Accordingly, if the devastating physical and emotional effects problem of substance abuse among medical substances such as tobacco, alcohol, and students is to be adequately addressed, other drugs can cause. QUICK FACTS If you keep doing it… Your kids are more likely to pick up your bad habits You can have more trouble getting pregnant Your child has double the risk of ADD You may become impotent You can develop cancer If you quit… Your blood pressure normalizes Your chance of heart attack decreases Your sense of smell and taste improves You circulation and breathing improve You will eliminate that stress “In a word, I was too cowardly to do what I knew to be right, as I had been too cowardly to avoid doing what I knew to be wrong.” -Charles Dickens “You cannot run away from weakness; you must some time fight it out or perish; and if that be so, why not now, and where you stand?” -Robert Louis Stevenson 10 ©American Medical Student Association/Foundation, 2001 ON A CULTURE OF ABUSE This culture of abuse conflicts with the Since the 1960’s medical student abuse, renewed commitments of medical in the form of hostility and harassment, educators and practice professionals to has been recognized as a problem in instill in students a higher degree of American medical schools.28 This controversial issue has been repeatedly professionalism and cultural 30 sensitivity. neglected by many, regardless of the substantial evidence in literature documenting the prevalence and Silver and Glicken defined abuse as: “to deleterious effects of these practices. treat in a harmful, injurious, or offensive way; to attack in words; to speak Surprisingly enough, it wasn’t until the insultingly, harshly, and unjustly to or 1980’s that medical student abuse was about a person.”31 These avoidable, unnecessary, and harmful abuses have a properly addressed through academic research and preventive practices. long-term negative effect on students, resulting in inferior learning, lowered Despite these facts, medical schools’ self-esteem, depression, and lessassociate and assistant deans consistently effective patient care. Moreover, deny the existence of abuse at their students have even considered dropping institutions attributing negative feelings experienced by students to a out of school due to this continuous “challenging clinical curriculum.”29 mistreatment.32 “AMSA believes that all medical students have the right to learn in an environment free from harassment and discrimination based on ethnicity, sex, sexual orientation, religion, disability, or gender; thus, supports this right with all available means, including referral to legal services.” (AMSA-1997) PUTTING WORDS INTO ACTIONS If real, genuine changes are to be effected, and free from retaliation complaint-handling medical students and faculty, as well as procedures; and conduct preventive institutions as a whole must take assertive educational programs. actions on preventing student abuse. A few Rights and Duties: Institutions must focus procedures proposed by researchers in this on the wide promulgation of their respective field, and established by the LCME are as rights and duties to students, faculty 33 follows : members, residents, and nurses. Accreditation standards: All faculty Respect and Accountability: Students, as members, including residents, must be fully well as faculty members, must be made informed about the educational objectives of accountable for their actions and properly the courses and be prepared for their roles as evaluated for either promotion or teachers and educators of medical students. penalization. Effective teaching requires knowledge of the Drawing the line: Students and faculty must discipline and an understanding of come to terms with a clear definition of pedagogy. Medical schools must define the abuse, setting it apart from perceived standards of conduct in the teacher-learner mistreatments in order to foster a stimulating relationship; develop timely, confidential, and humanistic learning environment. "I have sworn upon the altar of God, eternal hostility against every form of tyranny over the mind of man." -Thomas Jefferson 11 ©American Medical Student Association/Foundation, 2001 FREQUENTLY ASKED QUESTIONS promotion programs for medical 1. What is the Medical Student Bill of students. Rights (MSBR)? The MSBR was adopted by AMSA in 4. Are there any other primers on well1999 as part of its Principles regarding being issues? students’ rights and responsibilities. You Certainly, at present, the following primers are available: A Primer on can access it online at http://www.amsa.org/sc/msbr.html Resident Work Hours: A Patient’s Safety Concern, and Medical Student Activism: 2. What are the Bell Regulations? After the death of Libby Zion in 1984, A Primer on Domestic and International the Ad Hoc Advisory Committee on Tobacco Control. They are available through the AMSA National Office, or Emergency Services (1987), chaired by Dr. Bertrand Bell, was formed to review you may contact the Director of Student Programming at 1·800·767·2266 ext.270 the grand jury’s report. The committee or at dsp@www.amsa.org. issued recommendations for graduate medical education reform to the New 5. How can I get involved in wellness York State Department of Health. In issues? 1989 these recommendations became There are many ways to address part of the New York State Health Code wellness at your medical school. On the under Section 405, limiting residents’ AMSA Website, you can find several working hours. They are commonly program ideas that have been tried at known as the Bell Regulations, after medical school campuses across the Bell. You can find a copy of this section country. You can also work at the through our Web site or at AMSA national office in Reston, VA, http://www.health.state.ny.us/nysdoh/phf for a month as a Well-Being intern with orum/nycrr10.htm (Table of Contentsthe Director of Student Programming. Search: section 405.4/ “medical staff”). You can always contact the DSP at or at dsp@www.amsa.org 3. Where can I find research papers on 1·800·767·2266 ext. 270 to talk about medical student well-being issues? AMSA has compiled an extensive ways to get involved or to discuss any wellness issue. bibliography on numerous research papers, including the ones cited on this 6. What can I do if I feel that I am being primer, which will be made available abused or mistreated at my school? through our Medical Student Well Being AMSA has an advocacy Board that can web page at www.amsa.org. The topics help you sort out your rights as a included are: stress, depression, student. Contact the DSP at the number substance abuse, medical student abuse, above for more information. suicide, well-being programs and committees, health policy, and health “It is not so much that we need to be taken out of exile. It is that the exile must be taken out of us” - The Lubavitcher Rebbe 12 ©American Medical Student Association/Foundation, 2001 ♦ ♦ ♦ ♦ ONLINE RESOURCES if trying to cut your caffeine intake, or http://www.amsa.org/well just want to learn more about it. AMSA’s Medical Student Well-Being Web Page. Contains information on ♦ http://www.cspinet.org./reports/food.htm various well-being issues, the Medical Here’s a list of food additives to avoid, Student Bill of Rights, Well-Being Topic this site tells you which ones and why. of the Month, MSWB Programming ♦ http://www.mindtools.com/ Ideas, Internship Opportunities, Online This site gives you some ideas on stress Resources in PDF format, and more. and time management. It’s also “a resource of thinking skills, shareware http://intelihealth.com InteliHealth is one of the leading online and practical psychology helping you to health information companies in the think your way to an excellent life!” world. It is a subsidiary of, and funded ♦ http://primusweb.com/fitnesspartner/libr by Aetna U.S. Healthcare. It contains ary/weight/stresmgt.htm reliable information on health Here you will find some very useful promotion, well-being, stress-reduction, stress-management techniques. nutrition, and more. ♦ http://students.ubc.ca/health http://www.cma.ca This is the University of British This is the Canadian Medical Columbia Student Health Web site. Here Association web page. It contains useful you will find information on health, information on well-being policies illness, and wellness issues from a adopted in this country medical perspective. http://www.cma.ca/inside/policybase/19 ♦ http://www.nhyoko.med.navy.mil/wellne 98/05-05.htm. ss/wellness.htm It also has a compilation of health and The Wellness Center at the U.S. Naval medicine-related Internet sites called Hospital in Yokosuka, Japan offers a WebMed Links, in which you can find wide range of information on wellness research done on various medical fields. issues including, nutrition, suicide http://www.cspinet.org./nah/caffeine.htm prevention, stress management, sexual This site is called Caffeine: The Inside health, and stress management. Scoop. It contains a list of facts and myths on caffeine, you may find it useful “We must learn to live together as brothers or perish together as fools.” --Martin Luther King, Jr. 13 ©American Medical Student Association/Foundation, 2001 Notes for Concerned Medical Students by Patch Adams, M.D., Founder and Director, Gesundheit Institute heartfelt medical education in exuberant anticipation Medical education can be a stressful experience. For of a life in service to humankind. Inherent in helping some, the academics seem gargantuan, for others the others is an intoxication of self-satisfaction in a costs are stifling. But the most disconcerting garland of intimacy. The keys here are to assert your feedback is the feedback that is centered on a own motivation and to respect your wisdom...indeed depression and anxiety over the kind of climate in to be bathed in the self-confidence that you can make which health care is practiced in today’s society. It is your life a delightful adventure. We offer a few hard to find joyous service oriented practice in suggestions here to make your education a highlight hospitals. So often it appears that economics and of your life. Please share your feedback and management come before patient care. Competition suggestions. Dialogue with us and your seems to be more the style than cooperation among contemporaries in creating a medical celebration. health professionals. This guide is created for the medical student who wishes a thrilling, joyous, Practice being very deep and intimate with each other. Hold nothing back. 5. Please get involved in the politics of medicine from the very beginning. Belong to the American Holistic Medical Association (AHMA), American Medical Student Association (AMSA), Office of Student Representatives (OSR) of the Association of American Medical Colleges, the American Medical Association (AMA), the American Academy of Family Physicians (AAFP), etc. Go to the meetings, especially the big ones, and talk with everyone. There is gold everywhere. Many are thinking about the same things you are. Your fantasy medical practice may sprout in this climate. 6. Yes, fantasize your most outlandish medical fantasy. Your degree in medicine is the freedom to choose exactly how you want to practice. The only limiting factors will be your fears and your imagination. Band together and soar. 7. Focus on medicine as service. Medicine as a business is hurting everyone. The rewards in medicine are in helping others and in selfdiscovery. Giving is an intoxication, intimacy is a by-product. Brace yourself for an avalanche of love. 8. This is a whopper. Have outside interests! You are not a doctor. You are a person who has studied medicine. You are all of your other interests just as well. Nurture all of your loves. Experiment with ways of integrating your interests with your medicine. Weave these interests into the relationships you have with your patients. Be open to learning things from them....you will love the bonds that form. 9. Finally, do not sacrifice your family for your medical career. What you learn in keeping your family vibrant will serve you greatly with your patients. Please cherish your significant others, your lovers, your children, your parents, and feel the great health their love gives you. See your friends as part of your family. 1. Don’t wait until you are on the wards to practice and develop your interviewing skills...start now! Interview everyone with as great a depth as you dare. Medicine’s fundamental thrill is intimacy. Find that kind of demeanor in yourself that delights others so they tell you their tales. Be ecstatic for the gift that people give you in love, trust and intimacy. Find a way to let this journey together stimulate you and fill you with the excitement of a new friend. 2. As you explore the glorious mechanisms of the body and life, let it electrify you in wonder and curiosity. Never get complacent over the miracle of life. Live in awe. Let this be the focus of your education...NOT your grades, which will tell you nothing about the kind of doctor you will be. (When I was in medical school, I told them never to notify me about my grades unless I failed...which became very freeing). 2. Do not let the cost of education paralyze you. It is a privilege that you are so fortunate to be in school. When you finish you will pay your loans back as soon as you can. If you choose serviceoriented medicine, its gift is payback enough until funds come in. Don’t let the debt trap you in a repugnant practice. Here creativity and exploration make great playmates. There is no debtor’s prison. Community support can be key here. 3. Cultivate intimacy with the health professionals and professors you respect. Invite yourself to their homes. Establish a thriving dialogue. Ask to come into their practice. Reach out for the same intimacy with aides, orderlies and nurses as you do with doctors and patients. The word here is friendliness wherever you go in life; it will make your day thrilling. 4. Please have support groups. Support in study. Support in play. Find like minds and fantasize your medical interests and futures. 14 ©American Medical Student Association/Foundation, 2001 1 MULLER S. Physicians for the 21st century. Report of the Project Panel of the General professional education of the Physician and College for Medicine. J Med Educ 1984; 59:1-208. 2 WOLF TM. Stress, coping and health: enhancing well-being during medical school. Med Educ 1994; 28(1):8-17. 3 AMSA 2000-2001 PPP http://www.amsa.org/about/ppp/contents.cfm 4 SHAPIRO SL, SHAPIRO DE, SCHWARTZ GER. Stress management in medical education: A review of the literature. Acad Med 2000; 75:748-759. 5 ROSAL MC, OCKENE IS, et al. A longitudinal study of students’ depression at one medical school. Acad Med 1997; 72:542-546. 6 CLARK DC, ZELDOW PB. Vicissitudes of depressed mood during four years of medical school. JAMA 1988; 260(17):2521-2528. 7 VALKO RJ, CLAYTON PJ. Depression in the internship. Dis Nerv Syst 1975; (36):26-29. 8 Physician Health and Well-Being [CMA Policy Summary]. Can Med Assoc J 1998; 158(9):11911195. (http://www.cma.ca/cmanews/vol-10/issue8/004.htm) 9 ROSS M. Suicide among Physicians. Psychiatry Med 1971; 2(3):189-198. 10 HAYS LR, CHEEVER T, PATEL P. Medical student suicide, 1989-1994. Am J Psychiatry 1996; 153:553-555. 11 AASLAND OG, ECKEBERG O, SCHWEDER T. 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